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Showing papers in "American Journal of Geriatric Pharmacotherapy in 2009"


Journal ArticleDOI
TL;DR: Despite disappointing results from recently completed Phase III trials of several novel compounds, the extent and breadth of activity at all phases of clinical development suggest that new pharmacotherapeutic options for the treatment of AD will become available within the next decade.
Abstract: Objective To provide a brief survey of the clinical development of Alzheimer's disease (AD) pharmacotherapy.

150 citations


Journal ArticleDOI
TL;DR: Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing, and a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.
Abstract: Background : Some older adults receive potentially inappropriate medications (PIMs), increasing their risk for adverse events. A literature search did not find any US multicenter studies that measured the prevalence of PIMs in outpatient practices based on data from electronic health records (EHRs), using both the Beers and Zhan criteria. Objectives : The aims of the present study were to compare the prevalence of PIMs using standard drug terminologies at 2 disparate institutions using EHRs and to identify characteristics of elderly patients who have a PIM on their active-medication lists. Methods : This cross-sectional study of outpatients' active-medication lists from April 1, 2006, was conducted using data from 2 outpatient primary care settings: Intermountain Healthcare, Salt Lake City, Utah (center 1), and the Cleveland Clinic, Cleveland, Ohio (center 2). Data were included from patients who were aged ≥65 years at the time of the last office visit and had ≥2 documented clinic visits within the previous 2 years. The primary end point was prevalence of PIMs, measured according to the 2002 Beers criteria or the 2001 Zhan criteria. Results : Data from 61,251 patients were included (36,663 women, 24,588 men; center 1: 37,247 patients; center 2: 24,004). A total of 8693 (23.3%) and 5528 (23.0%) patients at centers 1 and 2, respectively, were documented as receiving a PIM as per the Beers criteria; this difference was not statistically significant. Per the Zhan criteria ( P Conclusions : In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations. Female sex, polypharmacy, and number of primary care visits were significantly associated with PIM prescribing. In this analysis of data from elderly patients at 2 outpatient centers, a small set of 8 medications accounted for the majority of PIMs at both centers, irrespective of geographic and demographic variations.

128 citations


Journal ArticleDOI
TL;DR: Overall, these medications appeared to be beneficial in dementia, but only ACE inhibitors and diuretics significantly reduced the risk for and progression of dementia in the majority of studies.
Abstract: Background: Hypertension appears to contribute to the development of dementia. Antihypertensive drugs may play an important role in altering the incidence or progression of dementia, particularly dementia of the vascular type; however, the neuroprotective effects of these agents in other types of dementia are not well characterized. Objectives: The main aims of this review were to examine the relationship between use of antihypertensive agents and the incidence and progression of Alzheimer's dementia (AD), vascular dementia (VaD), and unspecified dementia, and to consider whether these agents may be neuroprotective. Methods: A search of the English-language literature (January 1996–August 2009) was conducted using PubMed, Ovid MEDLINE, EBSCO MEDLINE, and the Cochrane Database of Systematic Reviews for publications mentioning both antihypertensive drugs and dementia. A combination of searches was performed using the following terms: antihypertensive drugs, dementia, cognitive impairment, Alzheimer's dementia, vascular dementia, progression of cognitive impairment, severity of cognitive impairment, severity of dementia, prevalence, and incidence. Searches were also performed using the names of antihypertensive drug classes. The bibliographies of all retrieved articles were reviewed for additional relevant publications. The focus was on randomized controlled trials, cohort studies, and case—control studies, excluding studies in animals, patients aged Results: Sixty–five potentially relevant articles were identified from the 536 publications retrieved by the literature search. After application of the exclusion criteria, 12 original studies were included in the review, all published between 1999 and 2008 and most involving patients with AD or VaD. The most frequently studied antihypertensive agents were calcium channel blockers (7 studies), diuretics (6 studies), and angiotensin-converting enzyme (ACE) inhibitors (6 studies). Overall, these medications appeared to be beneficial in dementia, but only ACE inhibitors and diuretics significantly reduced the risk for and progression of dementia in the majority of studies. Conclusions: Antihypertensive medications—particularly ACE inhibitors and diuretics—may be helpful in reducing the risk for and progression of dementia. Large randomized clinical trials are warranted to further explore the relationship between antihypertensive drugs and dementia.

114 citations


Journal ArticleDOI
TL;DR: In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults with depression, fatigue, or apathy, with monitoring for response and adverse effects, are appropriate.
Abstract: Background: Depressive symptoms, fatigue, and apathy are common symptoms among medically ill older adults and patients with advanced disease, and have been associated with morbidity and mortality. Methylphenidate has been used to treat these symptoms because of its rapid effect. Despite the long history of methylphenidate use for the treatment of depressive symptoms, fatigue, and apathy, there is little definitive evidence to support its use. Objective: The aim of this paper was to review the efficacy and tolerability of methylphenidate in the treatment of depressive symptoms, fatigue, and apathy in medically ill older adults and adults receiving palliative care. Methods: English-language articles presenting systematic reviews, clinical trials, or case series describing the use of methylphenidate for the treatment of depressive symptoms, fatigue, or apathy in medically ill older adults or adults receiving palliative care were identified. The key words methylphenidate and either depressive, depression, fatigue, or apathy were used to search the Cochrane Database, MEDLINE, PsycINFO, and International Pharmaceutical Abstracts. Included articles addressed depressive symptoms, fatigue, or apathy in (1) older adults (generally, age ≥65 years), particularly those with comorbid medical illness; (2) adults receiving palliative care; and (3) adults with other chronic illnesses. I excluded articles regarding treatment of depression in healthy young adults; bipolar disorder and attention-deficit/hyperactivity disorder; and narcolepsy, chronic fatigue syndrome, and related disorders. Results: A total of 19 controlled trials of methylphenidate in medically ill older adults or patients in palliative care were identified. Unfortunately, their conflicting results, small sample sizes, and poor methodologic quality limited the ability to draw inferences regarding the efficacy of methylphenidate, although evidence of tolerability was stronger. The available evidence suggests possible effectiveness of methylphenidate for depressive symptoms, fatigue, and apathy in various medically ill populations. Conclusion: In the absence of definitive evidence of effectiveness, trials of low-dose methylphenidate in medically ill adults with depression, fatigue, or apathy, with monitoring for response and adverse effects, are appropriate.

102 citations


Journal ArticleDOI
TL;DR: Older adults trusted physicians and pharmacists more than the other sources studied to provide information on prescription drugs, and trust in physicians to provide price information was an important moderator of the effect of high drug spending on cost-related nonadhcrence.
Abstract: Background: Cost-related nonadherence to medieations is common among older adults, yet physician-patient communication about medication cost concerns is infrequent. One factor affecting communication and adherence may be older adults' confidence in the information about prescription drugs provided by physicians and other sources. Objectives: This study was conducted to identify which source older adults most trust to provide information on drugs and to examine the relationship between older patients' trust in physicians to provide price information and the occurrence of cost-related nonadherence. Methods: We conducted a cross-sectional national telephone survey of individuals aged ≥50 years who were taking at least 1 prescription medication. Respondents were asked how much they would trust various sources (physician, pharmacist, nurse, insurance plan, the Internet, consumer groups, friends and family) to provide helpful information on “the price of the prescription medicine compared to others like it” and on “how well the prescription medicine will work for you compared to other medicines like it.” The response options were a lot, somewhat , and not at all . Other measures of interest were respondents' beliefs concerning physicians' ability to lower drug costs and patient activation. We also evaluated the potential association between trust in physicians to deliver drug price information and cost-related medication nonadherence. Results: Compared with the other sources of information studied, doctors and pharmacists were the sources that respondents were most likely to trust “a lot” to provide information on drug prices (55.6% and 61.7%, respectively) and to provide information on drug effectiveness (79.9% and 66.4%). Less than half (42.3%) of respondents who said that they trusted their doctor to provide drug price information “somewhat” or “not at all” agreed that there are ways doctors could lower drug costs ( P = 0.01 vs those who trusted their doctor “a lot”). Adults aged ≥65 years were more likely than those aged 50 to 64 years to trust their doctors “a lot” to provide information on drug prices (odds ratio [OR] = 1.44; 95% CI, 1.08–1.92); the same was true of members of minority groups compared with white respondents (OR = 1.72; 95%) CT, 1.1 3–2.61 ). Among individuals with high drug spending, those who placed “a lot” of trust in their doctors to provide price information were less likely than those who trusted their doctor “somewhat” or “not at all” to have cost-related nonadhcrence (OR = 0.40; 95% CI, 0.20–0.78). Conclusions: In this survey, older adults trusted physicians and pharmacists more than the other sources studied to provide information on prescription drugs. Trust in physicians to provide price information was an important moderator of the effect of high drug spending on cost-related nonadhcrence. Efforts to provide patients and their providers with comparative data on drug prices and effectiveness may reduce cost-related nonadhcrence.

99 citations


Journal ArticleDOI
TL;DR: It was found that polypharmacy was common in older cancer patients and increased during hospitali-zation, and most OACE team recommendations communicated to physicians were implemented even though the primary physicians were not members of the O ACE team.
Abstract: Background: A novel Oncology-Acute Care for Elders (OACE) unit that uses an interdisciplinary team to enhance recognition and management of geriatric syndromes in hospitalized older adult cancer patients has been established at Barnes-Jewish Hospital (St. Louis, Missouri). The OACE team includes a clinical pharmacist whose primary role is to improve the appropriateness of prescribing. Objective: Using polypharmacy as the prototypical geriatric syndrome addressed by the OACE team, the objective of this study was to document the processes of communication of an interdisciplinary team and the impact on polypharmacy when the treating physician did not participate in the daily interdisciplinary team rounds. Methods: This was a prospective, observational study of older cancer patients admitted to the OACE unit. We tracked processes and outcomes of interdisciplinary communication regarding medications by prospectively recording OACE team recommendations and evaluating the frequency of implementation of these recommendations through a chart review. Treating physicians, who did not attend team rounds, received these recommendations on a communication form placed in the patient's chart. Results: Forty–seven patients were included in the study. The mean (SD) age was 73.5 (7.5) years. Twenty–one percent (10/47) of patients were prescribed ≥1 Beers medication as part of their home-care regimen before admission to the OACE unit. The OACE team made 51 medication recommendations, and 42 of those recommendations (82%) were implemented. Twenty–five patients (53%) had an alteration in their medication regimen; 13 (28%) had a potentially inappropriate medication discontinued. A medication error was corrected in ~1 of every 8 patients (6/47 [13%]). Conclusions: We found that polypharmacy was common in older cancer patients and increased during hospitali-zation. We also found that most OACE team recommendations communicated to physicians were implemented even though the primary physicians were not members of the OACE team. Future randomized trials are needed to assess the impact of the OACE team model of care on adverse events, survival, and cost in hospitalized older adult cancer patients.

80 citations


Journal ArticleDOI
TL;DR: There is a scarcity of data regarding the use of pharmacologic agents in older adults with T2DM, and clinical guidance is largely based on data obtained from younger populations.
Abstract: Background: Pharmacologic options for the treatment of elderly patients with type 2 diabetes mellitus (T2DM) are the same as in younger adults; however, treatment considerations differ in the elderly due to changes in renal and hepatic function, life expectancy, and various other clinical and practical considerations. Objective: This article discusses geriatric considerations in the pharmacologic management of T2DM and reviews the potential clinical advantages and disadvantages of pharmacologic agents currently available for the treatment of T2DM, including oral and injectable medications. Methods: A search of MEDLINE was conducted for articles published in English between January 1966 and September 2009 using the terms type 2 diabetes mellitus, elderly, geriatric, treatment, insulin, metformin, sulfonylurea, thiazolidinedione, α-glucosidase inhibitor, meglitinide, DPP-4 inhibitor, colesevelam, exenatide, and pramlintide. Meta-analyses, randomized controlled trials of pharmacologic treatment, and evidence-based reviews and/or expert opinions regarding the treatment of T2DM in the elderly were selected for review. Results: In overweight patients, metformin has been associated with reductions in risk for all-cause mortality and stroke compared with insulin and sulfonylureas. Older patients who are frail, anorexic, or underweight and those with congestive heart failure (CHF), renal or hepatic insufficiency, or dehydration may not be appropriate candidates for metformin therapy. The substantial risk of hypoglycemia with insulin secretagogues is increased by 36% in the elderly compared with younger adults; however, this risk is counterbalanced by the extensive clinical experience with these agents in the geriatric population. Thiazolidinediones should generally be avoided in patients with CHF and are absolutely contraindicated in patients with class II–IV heart failure. They have been associated with peripheral edema, as well as with decreases in bone mineral density in women. There is limited information on the use of dipeptidyl peptidase-4 inhibitors in the elderly, although dose adjustment is required in patients with renal compromise. In practice, substantial gastrointestinal adverse effects limit the use of α-glucosidase inhibitors in older patients. Colesevelam is associated with numerous drug interactions and can cause new or worsening constipation. There are limited data on the use of exenatide in the elderly. It may be beneficial in older patients with limited mobility who could benefit from weight loss, whereas it may not be a good option for frail, underweight adults. Use of exenatide is not recommended in patients with a creatinine clearance <30 mL/min. Given the increased monitoring required to avoid hypoglycemic events with pramlintide, this agent should be used with caution in older adults, particularly the frail elderly. Most patients with T2DM eventually require insulin; however, due to the risk of hypoglycemia and related morbidity, careful use of insulin is warranted in the geriatric population. Conclusions: Overall, there is a scarcity of data regarding the use of pharmacologic agents in older adults with T2DM, and clinical guidance is largely based on data obtained from younger populations. The selection of appropriate drug regimens for these patients remains challenging.

74 citations


Journal ArticleDOI
TL;DR: In this well-monitored geriatric population with chronic AF, including patients with falls and/or dementia, a high percentage were prescribed warfarin, with low rates of stroke, hemorrhage, and death at 12 months despite a low TTR.
Abstract: Background: Anticoagulation for stroke prevention is underused in elderly patients with nonvalvular atrial fibrillation (AF). Those with falls and/or early dementia may be at particular risk for stroke and hemorrhage. Objective: The aim of this study was to determine the prescribing patterns, risks, and benefits of anticoagulation with warfarin or acetylsalicylic acid (ASA) in elderly patients with AF at risk for stroke and hemorrhage, including those with falls and/or dementia. Methods: In this single-center, retrospective, observational study, data from patients aged ≥65 years with chronic nonvalvular AF treated at an urban academic geriatrics practice over a 1-year period were included. Eligible patients were receiving noninvasive management of AF with warfarin or ASA. Data were assessed to determine the prevalences of stroke, hemorrhage, falls, and the possible effects of anticoagulation with dementia. Outcomes events at 12 months, including time-in-therapeutic range (TTR), stroke, hemorrhage, and death, were determined. The stroke risk in each patient was estimated using the CHADS2 (congestive heart failure, hypertension, age ≥75 years, diabetes, history of stroke or transient ischemic attack) score, and the risk for hemorrhage was estimated using the Outpatient Bleeding Risk Index. Results: A total of 112 patients (mean age, 82 years) were identified; 106 were included in the present analysis (80 women, 26 men); 6 were not receiving antithrombotic therapy and thus were excluded from the analysis. Warfarin was prescribed in 85% (90 patients); ASA, 15% (16). International normalized ratio testing was done frequently, with a median interval of 13.7 days between tests (92% within 28 days). No association was found between an improved TTR and the number of tests per unit of time or the number of patients per clinician. The distributions of both the CHADS2 and Outpatient Bleeding Risk Index scores were not significantly different between the warfarin and ASA groups. The proportions of patients treated with warfarin were not significantly different between the groups with a high risk for hemorrhage and the groups at lower risk. At 12 months in the 90 patients initially treated with warfarin, the rate of stroke was 2% (2 patients); major hemorrhage, 6% (5); and death, 20% (18). Mortality was greater in patients with falls (45% [5/11]) and/or dementia (47% [8/17]) compared with those without either falls or dementia (12% [8/65]). Conclusions: In this well-monitored geriatric population with chronic AF, including patients with falls and/or dementia, a high percentage were prescribed warfarin (85%), with low rates of stroke, hemorrhage, and death at 12 months despite a low TTR. Patients with falls and/or dementia had a high mortality rate (~45%).

71 citations


Journal ArticleDOI
TL;DR: Medication underuse was relatively common in this study and patients with greater comorbidity, but not polypharmacy, had increased odds of undertreatment.
Abstract: Background: Medication underutilization, or the omission of a potentially beneficial medication indicated for disease management, is common among older adults but poorly understood. Objectives: The aims of this work were to assess the prevalence of medication underuse and to determine whether polypharmacy or comorbidity was associated with medication underuse among physically frail older veterans transitioning from the hospital to the community. Methods: This was a cross-sectional analysis of patients who were discharged from 11 US veterans' hospitals to outpatient care, based on data from the Geriatric Evaluation and Management Drug Study, a substudy of the Veterans Affairs Cooperative Study of geriatric evaluation and management. Patients were enrolled between August 31, 1995, and January 31, 1999. To qualify for the study, patients had to be aged ≥65 years, hospitalized in a medical or surgical ward for >48 hours, and meet ≥2 of the following criteria: moderate functional disability; recent cerebrovascular accident with residual neurological deficit; history of ≥1 fall in the previous 3 months; documented difficulty with walking (ie, requiring personal assistance or equipment), not including preadmission use of a wheelchair with ability to transfer to and from chair independently; malnutrition (admission serum albumin of 3.5 g/dL, <80% of ideal body weight, or recent ≥15-lb weight loss reported in admission history); dementia; depression; documented diagnosis of new fracture or revision needed of older fracture; unplanned admission within 3 months of previous admission; and prolonged bed rest. Clinical pharmacist/physician pairs reviewed medical records and medication lists and independently applied the Assessment of Underutilization (AOU) index to determine omissions of indicated medications. Discordances in index ratings were resolved during clinical consensus conferences. The primary outcome measure was the percentage of patients with ≥1 medication omission detected by the AOU. Multivariable logistic regression analyses identified factors associated with underuse. Results: A total of 384 patients were included in the study. The majority (53.6%) were between the ages of 65 and 74 years, and the mean (SD) Charlson comorbidity index was 2.44 (1.93). Overall, 374 patients (97.4%) were men and 274 (71.4%) were white. Medication undertreatment occurred in 238 participants (62.0%). Diseases of the Accepted for publication October 26, 2009. circulatory, endocrine/nutritional, musculoskeletal, and respiratory systems were the most commonly undertreated conditions. The indicated medications most likely to be omitted were nitrates for those with a history of myocardial infarction, multivitamins in those with malnutrition, and inhaled anticholinergics for chronic obstructive airways disease. Statistically significant factors associated with medication underuse included limitations in activities of daily living (adjusted odds ratio [AOR], 2.17 [95% CI, 1.27–3.71]; P = 0.01), being white (AOR, 1.70 [95% CI, 1.06–2.71]; P = 0.03), and Charlson comorbidity index (AOR, 1.13 for each 1-point increase [95% CI, 1.00–1.27]; P = 0.04). Discharge from a general medicine service as opposed to a surgical service was associated with lower risk of medication underuse (AOR, 0.61 [95% CI, 0.38–0.98]; P = 0.04). Conclusions: Medication underuse was relatively common in this study. Patients with greater comorbidity, but not polypharmacy, had increased odds of undertreatment.

69 citations


Journal ArticleDOI
TL;DR: Geriatricians should assume that the medication lists supplied by GPs are incomplete or incorrect, and be aware that in approximately 25% of patients, symptoms may be caused by medication use inaccurately described in the referral.
Abstract: Background: Increased age is associated with polypharmacy. Polypharmacy is a risk factor for severe adverse drug reactions (ADRs) and is associated with an increased risk of mortality. Objectives: The main goal of the current study was to describe the frequency and relevancy of discrepancies in drug use in Dutch geriatric outpatients as reported by the patients and their caregivers, documented by the referring general practitioner (GP), and registered by the public pharmacy. The frequency of medication discrepancy adverse patient events (MDAPEs) was also recorded. In addition, possible contributing factors—such as increasing age, cognitive status and depressive symptoms, the number of medications used, the number of physicians visited by the patient, and the presence of a caregiver to supervise medication use—were studied. Methods: This was a prospective descriptive study conducted at the geriatric outpatient clinic of a teaching hospital. Between January 1 and May 1, 2005, consecutive patients were included if they were aged >65 years, reported use of ≥1 medication, and if they could understand the goals and consequences of participating in the study. The medications described by geriatric patients and their caregivers were compared with the drugs listed by their GP. The pharmacies of the referred patients were asked to send a description of the drugs distributed in the 6 months preceding the patient's visit to the geriatric outpatient clinic. The classification of ADRs and undertreatment as clinically relevant was done by study investigators who were blinded for the presence of discrepancy. Results: A total of 120 outpatients were included. The mean (SD) age of the study patients was 82.3 (6.8) years; 71.7% were women. Of the 120 patients, 113 patients (94.2%) reported taking >1 drug and 88 (73.3%) were prescribed ≥4 drugs. At least 1 discrepancy between the medication lists of the patients, GP, or pharmacy was present in 104 of the 120 patients (86.7%). In 90 patients (75.0%), there was ≥1 discrepancy between the medication reported by the patient and the GP. Patients with ≥1 discrepancy reported taking a higher mean number of drugs and had more prescribing physicians in addition to their GP. Twenty-nine patients (24.2%) experienced an MDAPE involving the use of drugs the GP had not correctly described in the letter of referral. The pharmacy was unaware of the use of medication involved in an MDAPE in 2 patients. Conclusions: Geriatricians should assume that the medication lists supplied by GPs are incomplete or incorrect, and be aware that in ~25% of patients, symptoms may be caused by medication use inaccurately described in the referral. Reports by the community pharmacy may supply valuable additional information. Because there are also discrepancies between patients and pharmacies, medication use from a database—with data from prescribing physicians and pharmacy systems—will still have to be confirmed by the patient.

64 citations


Journal ArticleDOI
TL;DR: This review explores the risks and benefits of different classes of HF pharmacotherapy for chronic HF management in the elderly population and recommends that evidence-based therapy for HF be used in elderly patients, with individualized consideration of the elderly patient's altered ability to metabolize or tolerate standard medications.
Abstract: Background: In the United States, the incidence of heart failure (HF) in the elderly population (age, ≥65 years) approached 10 per 1000 population in 2006, and HF was a common reason for hospitalization. Many clinical features and the management of HF differ in elderly patients compared with their younger counterparts due to changes in physiology and the presence of comorbidities. Objective: The aim of this review was to explore the risks and benefits of different classes of HF pharmacotherapy for chronic HF management in the elderly population. Methods: Peer-reviewed articles were identified from MEDLINE and Current Contents database (both, 1966–May 21, 2009) using the search terms HF, elderly, geriatrics, angiotensin-converting enzyme (ACE) inhibitors, angiotensin receptor blockers (ARBs), β-blockers, aldosterone antagonists, diuretics, digoxin, and vasodilators. Citations from available articles were also reviewed for additional references. Randomized, double-blind, controlled studies that assessed the effects of HF pharmacotherapy on morbidity and mortality outcomes were included. The American College of Cardiology/American Heart Association (ACC/AHA) Clinical Guidelines on Management of Chronic HF and associated studies are discussed. Results: A total of 40 clinical studies were included in the present review. The ACC/AHA recommended that evidence-based therapy for HF be used in elderly patients, with individualized consideration of the elderly patient's altered ability to metabolize or tolerate standard medications. HF pharmacotherapies that have been associated with mortality benefits in elderly patients with left ventricular systolic dysfunction include ACE inhibitors or ARBs; β-blockers; aldosterone antagonists; and, in patients who cannot tolerate ACE inhibitors or ARBs or who are black, a combination of hydralazine and nitrates. For symptom control and morbidity benefit, therapies include diuretics and digoxin. For HF with preserved ejection fraction (HF-PEF), no particular pharmacotherapeutic agent has been found to have mortality benefits. Managing the underlying cause for the HF symptoms is the key approach to treatment of HF-PEF. There was a lack of clinical trials that assessed the effects of HF treatment exclusively in elderly patients. Most clinical trials of HF pharmacotherapy have not specified the number of elderly patients included, or they included 30% to 50% elderly patients. This lack of data in the elderly leads to the necessity of applying clinical judgment to individual patient cases, together with consideration of their altered ability to metabolize or tolerate standard medications. Elderly patients also have variable responses to HF pharmacotherapy and might be susceptible to adverse events, such as orthostatic hypotension, renal dysfunction, electrolyte disturbances, and interactions with medications being received for the treatment of comorbidities. Elderly patients undergoing HF therapy should be closely monitored. The HF-related mortality rate is high in elderly patients. Discussing end-of-life issues and providing palliative care in patients with advanced disease are parts of an optimal care plan. Conclusions: HF therapy that has published mortality and morbidity benefits in nonelderly patient populations has been associated with benefits in elderly patients. Elderly patients may have variable pharmacologic responses to these agents and may be susceptible to adverse events and drug-drug interactions due to concurrent treatments for comorbidities. Close monitoring of elderly patients undergoing HF treatment is essential to ensure optimal outcomes.

Journal ArticleDOI
TL;DR: Evidence indicates that the osteoporosis treatments currently available in the United States are beneficial for treating geriatric patients, however, data are limited for the oldest patients (> or = 80 years) and those with significant comorbidities.
Abstract: Background: Fractures are a significant problem in geriatric patients, and understanding the evidence for benefit and possible harm of osteoporosis treatments is critical to appropriate management of this patient population. Objective: The purpose of this article was to review the evidence and treatment considerations related to use of the approved osteoporosis treatments in the United States across the continuum of ages in the geriatric population. Methods: MEDLINE and the Web of Science were searched to find English-language articles published from 2000 through July 2009. Search terms included: practice guideline, osteoporosis, calcium, vitamin D, pharmacoeconomics, ethnicity, and treatment. The generic names of each of the osteoporosis treatments approved in the United States were searched to find relevant clinical trials and randomized controlled trials (RCTs). Pivotal trials that included fracture data or focused specifically on elderly patients (≥60 years of age) were selected. Bibliographies in the identified articles were searched for additional articles, and the prescribing information for each of the approved treatments was reviewed. Results: Many osteoporosis studies have a mean patient age >60 years, but data for older patients are limited. Subanalyses of older patient groups have found risedronate to be beneficial for vertebral fractures in patients aged 70 to 79 years (absolute risk reduction [ARR], 8.4%; P < 0.001) and teriparatide to be beneficial for both vertebral (ARR, 6.4%; P < 0.05) and new nonvertebral fragility fractures (ARR, 9.9%; P < 0.05) in women aged ≥75 years. However, no RCTs of geriatric patients who were either nonambulatory or had multiple comorbidities were identified in the literature. Conclusions: Evidence indicates that the osteoporosis treatments currently available in the United States are beneficial for treating osteoporosis in geriatric patients. However, data are limited for the oldest patients (≥80 years) and those with significant comorbidities. Because of the limited availability of data for geriatric patients with significant comorbidities, the properties of the various agents, including efficacy, tolerability, and potential contraindications, should be considered carefully for each geriatric patient.

Journal ArticleDOI
TL;DR: The geriatric palliative care team was associated with a reduction in the number of unnecessary medications prescribed for older veterans in this nursing home, which was seen in all 3 categories of the Unnecessary Drug Use Measure.
Abstract: Background: There is a lack of studies concerning improvement of medication use in palliative care patients in nursing homes. Objective: This study was conducted to evaluate whether a geriatric palliative care team reduced unnecessary medication prescribing for elderly veterans residing in a nursing home. Methods: This was a retrospective, descriptive study of patients who died while residing in a geriatric palliative care unit between August 1, 2005, and July 31, 2007. Prescribed medications were evaluated using the Unnecessary Drug Use Measure, which contains 3 items from the Medication Appropriateness Index concerning lack of indication, lack of effectiveness, and therapeutic duplication. This measure was applied at 2 time points: on transfer/admission to the palliative care unit and at the last 30-day pharmacist medication review before death. Paired t tests and McNemar tests were used to compare medication use at these 2 points. Results: Eighty-nine patients were included in the study. The majority were male (97.8%) and white (78.7%), with a mean (SD) age of 79.7 (7.8) years. The median length of stay on the unit was 39.0 days, and the mean number of chronic medical conditions was 8.4 (4.3). At baseline, the mean number of scheduled medications was 9.7 (4.3). The number of unnecessary medications per patient decreased from a mean of 1.7 (1.5) at admission to 0.6 (0.8) at closeout (P = 0.003). The decrease was seen in all 3 categories of the Unnecessary Drug Use Measure. Conclusions: The geriatric palliative care team was associated with a reduction in the number of unnecessary medications prescribed for older veterans in this nursing home. Future studies should evaluate the impact of decreasing unnecessary prescribing on clinical outcomes such as adverse drug reactions.

Journal ArticleDOI
TL;DR: In this small sample of VA patients with glaucoma, adherence to glAUcoma medications could be improved, especially among those who reported difficulties using their medications and those who were nonwhite.
Abstract: Objective: The purpose of the current study was to determine the self-reported prevalence of and factors associated with nonadherence with glaucoma medications in veteran outpatients. Methods: This survey study was conducted at a Veterans Affairs (VA) clinic. A survey was administered to patients with glaucoma. We calculated the percentage of self-reported adherence with glaucoma medications in each patient. Logistic regression was used to assess whether patient characteristics and difficulties with using glaucoma medications were related to patients' reporting that they were <100% adherent with their glaucoma medications in the previous week. Results: The survey was completed by 141 patients (men, 91.5%; mean [SD] age, 70.22 [11.60] years [range, 37–93 years]; black race, 45.4%; white race, 44.0%; “other” or data unavailable, 10.6%). Nonwhite patients were significantly less adherent in the previous week than were white patients (27.0% vs 11.3%; P < 0.05). A total of 67.4% patients reported ≥1 difficulty in using their glaucoma medications. The 3 most commonly reported difficulties were “drops fall on cheek” (29.1%), “too many drops come out” (20.6%), and “hard to read print” (17.0%). A total of 19.1% of patients self-reported using <100% of their glaucoma medications in the previous week. The number of difficulties reported was significantly associated with reporting being <100% adherent in the previous week (P<0.05). Conclusion: In this small sample of VA patients with glaucoma, adherence to glaucoma medications could be improved, especially among those who reported difficulties using their medications and those who were nonwhite.

Journal ArticleDOI
TL;DR: Genotype-guided warfarin therapy for anticoagulation in elderly patients with AF was potentially cost-effective, and its benefits were closely related to efficacy in preventing bleeding events.
Abstract: Background: In patients with atrial fibrillation (AF), anticoagulation with warfarin decreases the risk of embolic stroke by >50%. Identification of genetic polymorphisms in enzymes involved in the metabolism of warfarin can partially predict the maintenance dose and thus potentially decrease the incidence of bleeding episodes secondary to warfarin overdose. Objectives: The objectives of this study were to evaluate the potential clinical and economic outcomes of genotype-guided warfarin therapy in elderly patients newly diagnosed with AF and to identify a threshold in bleeding risk at which such therapy may be cost-effective. Methods: A decision tree was designed to represent the medical decision (pharmacogenetic testing or not) and the main clinical outcomes (embolic stroke, bleeding). Event rates of embolic stroke and bleeding complications were based on data from previously published clinical trials and an observational study, respectively; costs were from a third-party payer perspective; and utilities were from the patient perspective. It was assumed that use of pharma-cogenetic testing would not lead the clinician to make any potentially harmful modifications to the regimen. Results: This analysis found that any reduction in major bleeding as a result of pharmacogenetic testing would lead to improved utility. The higher costs of pharmacogenetic testing compared with no testing would be immediately offset by any reduction in major bleeding. Conclusions: In this decision analysis, genotype-guided warfarin therapy for anticoagulation in elderly patients with AF was potentially cost-effective, and its benefits were closely related to efficacy in preventing bleeding events. Clinical trials testing the efficacy of genotype-guided warfarin therapy are warranted.

Journal ArticleDOI
TL;DR: Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of cholinesterase inhibitors in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.
Abstract: Background: Cholinesterase inhibitors (CHEIs) ameliorate some types of behavioral symptoms in patients with Alzheimer's disease. However, there has been little previous study of the outcomes associated with discontinuing these medications. Objective: The primary aim of this study was to evaluate the extent to which discontinuing CHEI therapy affected behavioral and mood symptoms in a cohort of nursing home residents with a diagnosis of dementia compared with residents receiving longer-term CHEI therapy. Methods: This was a retrospective cohort study using Rhode Island Medicaid prescription claims and the Minimum Data Set (MDS). Participants were Rhode Island nursing home residents aged ≥60 years with a diagnosis of Alzheimer's disease or non-Alzheimer's dementia, treated with CHEI monotherapy, and enrolled in the Medicaid program between January 1, 2004, and December 31, 2005. The discontinuation cohort (CHEI-DC) was selected by identifying residents who received 3 to 9 months of uninterrupted CHEI therapy. The continuation cohort (CHEI-CONT) was prescribed continuous CHEI therapy for >9 months. Changes in scores on the Aggressive Behavior Scale (ABS) and the Depression Rating Scale (DRS) for CHEI-DC residents were compared with changes in scores for CHEI-CONT residents. Secondary outcomes included change over time for individual behavioral symptoms and indicators of cognitive and functional status coded on the MDS. Results: The final matched sample (N = 178) included 62 CHEI-DC cases and 116 CHEI-CONT controls. More than half of the cohort was aged ≥85 years, and the sample was predominantly female. A diagnosis of Alzheimer's disease was documented in 40.3% of the CHEI-DC patients and in 46.5% of the CHEI-CONT patients. Behavioral worsening, indicated by an increase in the estimated mean monthly point change in ABS score, occurred in the CHEI-DC group (0.08; 95% CI, 0.01 to 0.16) but not in the CHEI-CONT group (−0.01; 95% CI, −0.06 to 0.04), and the between-group difference was significant (0.09; 95% CI, 0.01 to 0.18). There were no significant between-group differences in the mean monthly point change in mood symptoms on the DRS (0.04; 95% CI, −0.03 to 0.12). For the secondary outcomes, the mean monthly MDS point change for frequency of repetitive verbal behaviors indicated that CHEI-DC patients exhibited significantly more episodes of repetitive questioning (0.17; 95% CI, 0.05 to 0.29) and repetitive health complaints (0.16; 95% CI, 0.04 to 0.27) compared with CHEI-CONT residents. Continued use of CHEIs was associated with more time spent in leisure-related activities over the study period (−0.26; 95% CI, −0.50 to −0.02), with the CHEI-DC group spending less time in activities (0.11; 95% CI, 0 to 0.23); the between-group difference was also significant (0.37; 95% CI, 0.10 to 0.65). Conclusion: Results of this retrospective analysis suggest that, compared with longer duration of CHEI therapy, discontinuation of CHEIs in these nursing home residents with dementia was associated with some adverse behavioral changes and decreased time spent engaging in leisure-related activities.

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TL;DR: A substantial proportion of those Ontarians aged > or = 60 years reported NHP use, and there is a need for greater communication with physicians to avoid potential drug-NHP interactions.
Abstract: Background: The self-reported use of natural health products (NHPs) (herbal products and vitamin and mineral supplements) has increased over the past decade in Canada. Because the elderly population might have comorbidities and concurrently administered medications, there is a need to explore the perceptions and behaviors associated with NHPs in this age group. Objective: The goal of this study was to assess the use of NHPs in a cohort of older Canadian residents and the characteristics, perceptions, and behaviors associated with NHP use. Methods: Survey participants aged ≥60 years were randomly selected from telephone listings in the area of greater Hamilton, Ontario, Canada. Data were collected using a standardized computer-assisted telephone interview system. Self-reported data covering 7 domains were collected: (1) demographics; (2) self-reported 12-month NHP use; (3) reasons for NHP use; (4) self-reported 12-month prescription medication use; (5) expenditures on NHPs; (6) patient-reported adverse events and drug-NHP interactions; and (7) perceptions of physicians' attitudes regarding NHPs. Descriptive statistics were used to compare the characteristics of NHP users with those of nonusers and to assess the characteristics of NHP users across these 7 domains. Multivariate regression analysis was conducted to determine the demographic variables that might be associated with NHP user status. Results: Of 2528 persons identified as age ≥60 years, 1206 (48%) completed the telephone interview. Six hundred sixteen of these respondents (51%) reported the use of ≥1 NHP during the previous 12 months. On the initial univariate analysis, younger age and higher income were significantly associated with reporting NHP use (mean age, users vs nonusers, 71.1 vs 72.7 years, respectively; 95% CI, 1.02–1.06; P < 0.001; income more than Can $26,000 was 28% and 22% in users and nonusers, respectively; P = 0.028). One hundred seventy of 616 users (28%) used an NHP to treat the same condition for which they were concurrently receiving a prescription medication, and 43 (25%) had not informed their physicians about their NHP use. Patients' characteristics such as sex, education, smoking status, and self-reported health status did not differ significantly between users and nonusers. In individuals who regularly spent money to purchase NHPs (n = 394), the mean cost was $20.38/mo. NHP expenditure was not significantly associated with age, sex, or income. Conclusion: Based on these findings, a substantial proportion of those Ontarians aged ≥60 years reported NHP use, and there is a need for greater communication with physicians to avoid potential drug-NHP interactions.

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TL;DR: The data suggest that hydromorphone and morphine in the doses given had similar efficacy and safety profiles in these older adults in the ED, and future investigations of acute pain management in older adults should examine the efficacy andsafety of higher initial (loading) doses of opioids titrated at frequent intervals.
Abstract: Background: Older adults (ie, those aged ≥65 years) are the fastest growing segment of the US population, with an estimated ~71 million expected by 2030. Over the past 10 years, there has been an 11% increase in the number of emergency department (ED) visits by older adults, and pain is their most common chief complaint. Objective: The goal of this study was to compare weight-based IV hydromorphone and IV morphine in adults aged ≥65 years presenting to the ED with acute, severe pain. Methods: This was a prospective, randomized, double-blind clinical trial of older adults with acute, severe pain at an adult, urban academic ED. Patients were randomly allocated to receive a single dose of 0.0075-mg/kg IV hydromorphone or 0.05-mg/kg IV morphine. The primary outcome was the between-group difference in decrease in pain from baseline to 30 minutes after the medications were infused. Patients' degree of pain was measured on a numerical rating scale (NRS) where “0” was defined as “no pain” and “10” was defined as “the worst pain possible.” Adverse effects, pain reduction at 10 minutes and 2 hours postbaseline, patient evaluations of satisfaction and pain relief at 30 minutes postbaseline, and use of additional analgesics and antiemetics were tracked as secondary outcomes. Results: A total of 194 patients were randomized to treatment; 183 patients (hydromorphone group, n = 93; morphine group, n = 90 [overall mean (SD) age, 75 (8) years]) had sufficient data for analysis at the primary end point of 30 minutes postbaseline. The mean decrease in pain from baseline to 30 minutes in patients allocated to IV hydromorphone was 3.8 versus 3.3 NRS units in patients allocated to IV morphine. This difference of 0.5 NRS unit (95% CI, −0.2 to 1.3) was neither clinically nor statistically significant. A majority of patients in both groups (57.0% randomized to hydromorphone and 58.9% randomized to morphine) failed to achieve a ≥50% reduction in pain within 30 minutes of treatment. The incidence of adverse effects from baseline to 30 minutes was not statistically different in the 2 groups. Conclusions: A single dose of IV hydromorphone at 0.0075 mg/kg was neither clinically nor statistically different from IV morphine at 0.05 mg/kg for the treatment of acute, severe pain at 30 minutes postbaseline in these older adults in the ED. The incidence of adverse effects was not statistically different. Our data suggest that hydromorphone and morphine in the doses given had similar efficacy and safety profiles in these older adults. Neither regimen provided ≥50% pain relief for the majority of patients. Future investigations of acute pain management in older adults should examine the efficacy and safety of higher initial (loading) doses of opioids titrated at frequent intervals until adequate analgesia is achieved.

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TL;DR: Antipsychotic use increased in US nursing homes from 1996 through 2006 and was associated with certain organizational characteristics and market characteristics, and future interventions to reduce antipsychotics use in nursing homes will have to focus on these factors.
Abstract: Objective: The aim of this work was to examine the association between organizational characteristics, market characteristics, and changes in antipsychotic medication use in US nursing homes over time. Methods: This was a longitudinal study comparing antipsychotic use in US nursing homes from 1996 through 2006 using Medicare and Medicaid data (the Online Survey Certification And Reporting system) and US Department of Health and Human Resources Health Resources and Services Administration data (the Area Resource File). The 3 outcomes of interest were increasing, decreasing, or stable use of antipsychotic medications. The primary independent variables were organizational characteristics (eg, for-profit status, chain membership) and market characteristics (eg, Medicaid reimbursement, levels of competition). Results: Antipsychotic use increased from 16.4% in 1996 to 25.9% in 2006 (P < 0.05). A multinomial generalized estimating equations model, controlling for facility, staffing, and resident factors, suggested that increased antipsychotic use was associated with for-profit facilities (adjusted odds ratio [AOR], 1.58; 95% CI, 1.51–1.65; P ≤ 0.001). Decreased antipsychotic use was associated with chain membership (AOR, 0.82; 95% CI, 0.79–0.85; P ≤ 0.001), higher levels of competition (AOR, 1.22; 95% CI, 1.16–1.29; P ≤ 0.001), and a higher Medicaid reimbursement rate (AOR, 0.88; 95% CI, 0.85–0.92; P ≤ 0.001). Conclusions: Antipsychotic use increased in US nursing homes from 1996 through 2006 and was associated with certain organizational characteristics and market characteristics. Future interventions to reduce antipsychotic use in nursing homes will have to focus on these factors.

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TL;DR: It is found that the utilization of health care resources and economic burden of LTC residents with COPD were primarily due to LTC, pharmacy, and inpatient costs.
Abstract: Background: Chronic obstructive pulmonary disease (COPD) is a leading cause of morbidity and mortality worldwide. COPD increases health care resource utilization and spending and adversely affects quality of life. Data from the clinical and economic outcomes in Medicare beneficiaries with COPD who reside in long-term care (LTC) facilities are limited. Objective: The purpose of this study was to investigate the clinical and economic outcomes associated with COPD in Medicare beneficiaries residing in LTC facilities. Methods: This retrospective cohort study analyzed data from MarketScan Medicaid, a large US administrative claims database containing data on Medicaid programs in 8 states. The study cohort comprised LTC facility residents aged ≥60 years who had a diagnosis of COPD. Eligible patients also had a prescription filled between January 1, 2003, and June 30, 2005, for one of the following COPD treatments: fluticasone propionate + salmeterol xinafoate, tiotropium bromide, ipratropium bromide, or ipratropium bromide + albuterol sulfate. The date of the first prescription fill was considered the index date. Measures of health care resource utilization included COPD-related and all-cause hospitalizations and emergency department (ED) visits. Cost analysis outcomes included COPD-related and all-cause inpatient, outpatient, pharmacy, LTC, and total costs during the 12-month postindex period. Results: Data from 3037 patients were included (63.0% women; 82.2% white; mean [SD] age, 78.1 [10.0] years). A total of 43.3% of patients had ≥1 hospitalization; 90.0%, ≥1 ED visit. With the exception of age <70 years, age was associated with all-cause hospitalization (age 70–<75 years, hazard ratio [HR] = 1.31 [95% CI, 1.03–1.68]; age 75–<80 years, HR = 1.40 [95% CI, 1.11–1.78]; age ≥80 years, HR = 1.48 [95% CI, 1.19–1.85]). Age was not associated with COPD-related hospitalization, all-cause ED visits, or COPD-related ED visits. The risk for all-cause hospitalization in white patients was significantly lower compared with that in nonwhite patients (HR = 0.79 [95% CI, 0.69–0.91]). Patients with comorbid asthma had a higher risk for a COPD-related ED visit (HR = 1.34 [95% CI, 1.08–1.66]) than did patients without asthma. Preindex all-cause hospitalization was associated with COPD-related hospitalization (HR = 1.78 [95% CI, 1.49–2.14]) and all-cause hospitalization (HR = 2.05 [95% CI, 1.932.19]). Twelve-month COPD-related and all-cause direct expenditures per beneficiary were US $7391 and $48,183. In COPD-related and all-cause estimates, mean (SD) LTC costs were the largest cost components ($5629 [$12,562] and $32,966 [$14,871], respectively), followed by pharmacy costs ($956 [$957] and $5565 [$3873]), inpatient costs ($466 [$3393] and $6436 [$22,603]), and outpatient costs ($341 [$1793] and $3216 [$6458]). Conclusion: This study found that the utilization of health care resources and economic burden of LTC residents with COPD were primarily due to LTC, pharmacy, and inpatient costs.

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TL;DR: The definitive survival advantage of irinotecan observed in clinical trials was not reproducible in this population of elderly Medicare patients, emphasizing the need for expansion of trials to include a more diverse patient group as well as continued evaluation of more recent chemotherapies in real-world settings.
Abstract: Background: Several population-based studies have confirmed the benefits of adjuvant chemotherapy with 5-fluorouracil/leucovorin for treatment of colorectal cancer. Few population-based studies have evaluated other chemotherapies that are now available for colorectal cancer management. Objective: This study primarily sought to evaluate the survival benefit of first-line irinotecan use in a group of Medicare patients with stage IV (metastatic) colorectal cancer. Methods: Data on chemotherapy users with a diagnosis of colorectal cancer reported between 1998 and 2002 were obtained from the Surveillance Epidemiology and End Results (SEER)-Medicare database. Irinotecan, marketed in 1997, was one of the newer chemotherapy agents in the available data. Chemotherapy episodes, defined as periods of continuous chemotherapy treatment with no gaps >90 days between successive claims, were identified. The first chemotherapy episode after diagnosis was used to identify lines of treatment: patients may have initiated irinotecan therapy within 2 months (first-line), used irinotecan later in the first episode (second-line), or not used irinotecan at all. Descriptive statistics were generated and a multivariable Cox proportional hazards model was used to determine the survival benefit of irinotecan. Secondary analyses explored the survival benefit in specific patient subgroups. The impact of irinotecan use on health care utilization also was assessed. Results: Of 3327 chemotherapy users (mean/median age, 75 years), 842 (25.3%) initiated chemotherapy using irinotecan. No overall survival benefit for irinotecan was observed in the primary analysis comparing irinotecan initiators with all other chemotherapy users (including those who used irinotecan subsequently). Covariates that were negatively associated with survival included older age, presence of >1 comorbidity, a high tumor grade, lymph node involvement, and a primary tumor site in the colon. Surgery was positively associated with a lower hazard of death. In subgroup analyses that excluded subsequent irinotecan users, a survival benefit for irinotecan was observed but diminished over time. Irinotecan users had higher rates of hospitalizations possibly due to chemotherapy-related adverse effects. This retrospective claims study had limitations such as a lack of information on patient performance status, dosing, and the types of regimens used; hence, certain assumptions had to be made and selection bias may have been involved. Conclusions: The definitive survival advantage of irinotecan observed in clinical trials was not reproducible in this population of elderly Medicare patients. The results emphasize the need for expansion of trials to include a more diverse patient group as well as continued evaluation of more recent chemotherapies in real-world settings.

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Jie Gu1, Yanyan Huang1
TL;DR: Caution should be used when administering meropenem and valproic acid concomitantly, especially in elderly patients with central nervous system disorders, even if the patient has had a successful prior experience with these 2 drugs.
Abstract: Background: Meropenem is a carbapenem with a broad spectrum of activity against β-lactamase-producing organisms. Valproic acid is widely used in the treatment of generalized tonic-clonic and partial seizures. Concomitant administration of meropenem and valproic acid reportedly leads to a rapid decline in serum concentrations of valproic acid, which is sometimes associated with seizures. Case summary: This report describes an 85-year-old Chinese male inpatient who twice received concomitant administration of meropenem and valproic acid for the treatment of pneumonia and poststroke epilepsy, respectively. Rapid declines in valproic acid concentrations were observed both times after meropenem administration. No seizures occurred in the first treatment period; however, when the patient suffered pneumonia again 3 months later, the same concomitant therapy was prescribed, and seizures occurred. It is difficult to identify a single etiology of the seizures. Based on a score of 7 on the Naranjo adverse drug reaction probability scale, the seizures were considered to be probably related to the concomitant administration of meropenem and valproic acid. Conclusions: Various factors make the effect of concomitant administration of meropenem and valproic acid unpredictable, even in the same patient. Caution should be used when administering meropenem and valproic acid concomitantly, especially in elderly patients with central nervous system disorders, even if the patient has had a successful prior experience with these 2 drugs. If concomitant administration is essential, very close serum concentration monitoring and clinical observation are necessary.

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TL;DR: The DAE RetroDUR was associated with a possible reduction in the use of potentially inappropriate prescription medications in these older adults, and further research is needed to show the impact on health care utilization and costs, adverse drug events, and health care and quality-of-life outcomes.
Abstract: Background: Use of potentially inappropriate medications or drugs to be avoided in the elderly (DAE) continues to be widespread. Although the literature suggests DAE are associated with negative health outcomes, educational interventions have had a positive impact on inappropriate prescribing. Objectives: The objectives of this study were to identify those members aged ≥65 years participating in a Medicare Part D Blue Cross and Blue Shield (BCBS) benefit plan who were receiving medications that may be inappropriate for use in older adults and, through a retrospective drug utilization review (RetroDUR), to notify their prcscribers of the possible safety concerns with continued use. Methods: The analysis used retrospective administrative pharmacy claims data from 3 Medicare Part D BCBS plans across 4 states. Plan members aged ≥65 years who had a claim for ≥1 DAE during a 30-day review period (August 15, 2007–September 14, 2007) with a minimum supply of 7 days of medication were identified. The National Committee for Quality Assurance 2007 Healthcare Effectiveness Data and Information Set measures for Medicare were used to determine DAE. A packet of information was mailed to prescribers identifying patients who had a claim for ≥1 DAE. Members were then assessed for the presence of a drug in the same drug class 6 months after the initial analysis. Results: Of a possible 328,000 eligible members, 16,973 (5.2%) had a claim for ≥1 DAE during the 30-day review period. A total of 7963 intervention prescriber letters were mailed, affecting 13,198 members with 14,267 DAE claims. The final analyzable intervention cohort consisted of 10,364 members with 11,062 DAE claims. Overall, 5403 claims (48.8%) for DAE were defined as discontinued after 6 months. The most common DAE in the study were estrogens, propoxyphene, muscle relaxants, anticholinergics, antihistamines, and nitrofurantoin, accounting for 9682 claims (87.5%). At the 6-month follow-up, reductions in claims for each of the top 6 drug/drug classes ranged from 31.3% to 66.7%. As a class, the anticholinergics had the highest rate of discontinuation. Conclusions: The DAE RetroDUR was associated with a possible reduction in the use of potentially inappropriate prescription medications in these older adults. Further research, using a control population, is needed to show the impact on health care utilization and costs, adverse drug events, and health care and quality-of-life outcomes.

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TL;DR: There was preferential prescribing of SSRI antidepressants among these older aged care home residents with depression, and cognitive impairment alone was not significantly associated with antidepressant prescribing; however, these aged careHome residents with dementia and mood disorders had an increased likelihood of being treated with antidepressants.
Abstract: Background: Depression is underrecognized and poorly treated among older people living in aged care homes worldwide. Depression has been associated with higher rates of recurrence, disability, and death in older people. Objectives: The primary objective of this study was to assess the determinants of antidepressant medication prescribing among older people living in aged care homes in Australia. A further objective was to investigate the anti-depressant medications in common use, doses of antidepressants, and concurrent pharmacotherapy among people receiving antidepressants. Methods: A random sample of 500 deidentified medication review reports was extracted from a database containing >165,000 Residential Medication Management Review reports. Residents' demographic and clinical characteristics, medical diagnoses, and prescribed medications were systematically extracted from these reports. Logistic regression models were used to determine factors associated with the prescribing of any antidepressant, including tricyclic antidepressants (TCAs), selective serotonin reuptake inhibitors (SSRIs), and “other” antidepressants (eg, mianserin, mirtazapine, venlafaxine). Results: The mean (SD) age of the residents was 84.0 (9.0) years. Seventy-five percent were female. The prevalence of antidepressant prescribing among these aged care home residents was 33.0%. SSRIs were more commonly prescribed than TCAs, monoamine oxidase inhibitors, and other antidepressants. Antidepressants were more likely to be prescribed in people treated for dementia with mood disorder (odds ratio [OR] = 9.70; 95% CI, 5.26–17.88), depression (OR = 13.28; 95% CI, 6.44–27.36), and Parkinson's disease (OR = 3.56; 95% CI, 1.37–9.23). SSRI prescribing was associated with dementia with mood disorder (OR = 5.85; 95% CI, 3.19–10.72) and depression (OR = 6.44; 95% CI, 3.38–12.26). TCA prescribing was associated with depression (OR = 2.95; 95% CI, 1.18–7.35) and concurrent benzodiazepine use (OR = 2.43; 95% CI, 1.03–5.72). Other antidepressant prescribing was associated with dementia with mood disorder (OR = 6.53; 95% CI, 3.15–13.50) and depression (OR = 5.00; 95% CI, 2.23–11.19). Conclusions: There was preferential prescribing of SSRI antidepressants among these older aged care home residents with depression. Cognitive impairment alone was not significantly associated with antidepressant prescribing; however, these aged care home residents with dementia and mood disorders had an increased likelihood of being treated with antidepressants. The prescribing of TCAs was significantly associated with concurrent benzodiazepine use.

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TL;DR: A case of chorea was reported in an elderly patient who was receiving gabapentin for the treatment of anxiety, indicating a probable adverse drug reaction.
Abstract: Background: Chorea is a hyperkinetic movement disorder characterized by irregular, flowing, nonstereotyped, random, involuntary movements Huntington disease (HD) and drug-induced chorea account for >50% of adult-onset cases Chorea associated with gabapentin, an anticonvulsant, has not been well documented Objective: The purpose of this article was to report a case of chorea that developed in an elderly man being treated with gabapentin for severe anxiety Case summary: A 75-year-old white man (height, 1651 cm; weight, 658 kg; body mass index, 196 kg/m2) with anxiety disorder not otherwise specified was admitted to a geriatric medicine psychiatric unit in Connecticut because of worsening symptoms of anxiety affecting his cognitive ability On evaluation, the patient had choreiform movements involving the neck, trunk, upper and lower extremities, and tongue The patient reported that symptoms began after taking gabapentin 300 mg PO TID (prescribed by his geriatrician) for the treatment of anxiety The patient had been taking gabapentin for >1 month when the symptoms first appeared There was no known family history of HD, and patient workup was unremarkable for other conditions (eg, vascular disease of the brain, progressive dementia, infectious and metabolic disorders) that might present with chorea The chorea lasted for ~4 months and resolved within 2 days after gabapentin discontinuation Conclusion: This article reports a case of chorea in an elderly patient who was receiving gabapentin for the treatment of anxiety After gabapentin discontinuation, the chorea resolved completely, indicating a probable adverse drug reaction

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TL;DR: The prevalence of transdermal fentanyl use was higher than that of morphine, oxycodone, and hydromorphone among people aged > or = 80 years residing in noninstitutional settings in Finland and suggests that organizational culture may have a strong impact on prescribing practices.
Abstract: Background: The use of opioids has increased rapidly in Europe and North America, and older people may be susceptible to opioid-related adverse drug events. The Finnish National Agency for Medicines has recommended that oral opioids be considered the first-line treatment when a strong opioid is required for severe pain. Objective: The objective of this study was to investigate and describe the age-, indication-, sex-, and geographic-specific utilization of transdermal fentanyl among older people residing in noninstitutional settings in Finland. Methods: Reimbursement data for fentanyl, morphine, oxycodone, and hydromorphone were extracted from the Finnish National Prescription Register for 2008. Age-specific population data were used to calculate the annual prevalence of opioid use for malignant and nonmalignant pain for patients aged ≤64, 65 to 69, 70 to 74, 75 to 79, 80 to 84, 85 to 89, 90 to 94, 95 to 99, and >99 years. The annual prevalence of transdermal fentanyl use was also calculated separately for each of the 21 hospital districts in Finland. Results: Reimbursement for transdermal fentanyl was paid to 2746 people for malignant pain and 6223 people for nonmalignant pain. The annual prevalence of transdermal fentanyl use for nonmalignant pain was lowest among men aged ≤64 years (2.2 users/10,000 men) and highest among women >99 years (539.2 users/10,000 women). The annual prevalence of transdermal fentanyl use was >47 times higher than that of morphine for nonmalignant pain among people aged 85 to 89 years and >97 times higher than that of morphine among people aged 90 to 94 years. A greater than 4-fold variation in the annual prevalence of transdermal fentanyl use was reported among the 21 hospital districts in Finland (range, 9.5–40.6/10,000 inhabitants). Conclusions: The prevalence of transdermal fentanyl use was higher than that of morphine, oxycodone, and hydromorphone among people aged ≥80 years residing in noninstitutional settings in Finland. The variation in use between hospital districts suggests that organizational culture may have a strong impact on prescribing practices. Our data highlight the need for further education regarding the appropriate use of opioids among older people.

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TL;DR: Overall, solifenacin was found to improve symptom bother, HRQoL, work productivity, activity participation, and reduced medical care resource utilization in these elderly subjects with OAB who continued to have urgency symptoms with tolterodine and were willing to try solifentacin.
Abstract: Background: Overactive bladder (OAB) is a common problem among the elderly and a financial burden to society. The prevalence of OAB increases with age and affects ≥25% of people aged ≥65 years. Objective: The goal of this exploratory subgroup analysis of the VESIcare Efficacy and Research Study US (VERSUS) was to assess changes in health-related quality of life (HRQoL), medical care resource utilization, work and activity impairment, and health utility among elderly patients with OAB who continued to have urgency symptoms with tolterodine and were willing to try solifenacin. Methods: This was a 12-week, multicenter, prospective, open-label, noncomparative, flexible-dosing study designed to assess the efficacy and tolerability of solifenacin. Patients who received tolterodine 4 mg/d for ≥4 weeks but continued to experience urgency symptoms (≥3 urgency episodes/24 hours) were enrolled. This exploratory analysis describes results from 2 elderly cohorts (patients 65 to 74 years and ≥75 years of age). After a washout period of ≥14 days, patients began treatment with solifenacin 5 mg/d with dosing adjustments allowed at week 4 (to 10 mg/d) and at week 8 (back to 5 mg/d for patients whose dose was increased to 10 mg/d at week 4). Outcomes were assessed using the OAB-q (a questionnaire specific to OAB and HRQoL), the Work Productivity and Activity Impairment-Specific Health Problem index, the Medical Care Use Index, and the Health Utilities Index Mark 2 and Mark 3 (HUI2/3), administered at the prewashout and week-12 visits. Results: The subgroup analysis included 108 patients 65 to 74 years of age and 86 patients ≥75 years of age. Patients in both age groups experienced significant improvement in HRQoL (P < 0.001), as well as significant reductions in nonprotocol-related office visits (P < 0.001) and activity impairment (P < 0.025). A significant reduction in the use of pads/diapers was reported for patients 65 to 74 years of age (P < 0.018), and patients in this age group who were working reported significantly less impairment related to OAB while working during solifenacin treatment than during tolterodine treatment (P < 0.042). No significant differences in HUI2/3 scores were observed in either of the elderly subgroups. Conclusions: Overall, solifenacin was found to improve symptom bother, HRQoL, work productivity, activity participation, and reduced medical care resource utilization in these elderly subjects with OAB who continued to have urgency symptoms with tolterodine and were willing to try solifenacin. This was an exploratory subgroup analysis of an open-label, noncomparative study; further research is needed to confirm these results.

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TL;DR: A pilot study was conducted to test the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease and foundings from this study will help to refine the program and subsequent testing, with the overall goal of improving the qualityof medication use and health outcomes in older Adults.
Abstract: Background: Medication-related problems are prevalent in older adults, contributing to increased harm and health care costs and negatively impacting quality of care. Older adults with psychiatric disease are at an increased risk because of their underlying disease and types of medications prescribed. Efforts to improve the quality of medication use often focus on select medication-related problems, select diagnoses, or predefined quality indicators; however, such an approach fails to consider the potential for multiple coexisting problems within individuals. Objective: A pilot study was conducted to test the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. This article describes the methodology of the study and details of the intervention, and presents baseline characteristics of the study population. Methods: English-speaking psychiatry outpatients aged ≥65 years taking ≥2 drugs that are active in the central nervous system were enrolled into a medication management program, in which medication management was provided by a clinical pharmacist for 6 months. Patients were evaluated at baseline, 3 months, and 6 months. Data were collected on the patients' demographic characteristics, health and medications, health literacy, functional status, symptoms of depression, health services utilization, quality of medication use, adherence, and patient satisfaction with the program. Results: One hundred seventy-three older adults were assessed for inclusion; 146 were not eligible, not reachable, or not interested in participating. Twenty-seven older adults were enrolled in the study, all but one of whom completed the 3- and 6-month visits. The mean (SD) age of the 27 participants was 74.7 (8.1) years; 63% were female, 74% were white, and 70% had no cognitive impairment. Conclusions: This pilot study tested the feasibility of a medication management program designed to improve the quality of medication use in older adults with underlying psychiatric disease. Findings from this study, which will be reported at a later date, will help to refine the program and subsequent testing, with the overall goal of improving the quality of medication use and health outcomes in older adults.

Journal ArticleDOI
TL;DR: Cautious use and additional monitoring may be necessary when prescribing levetiracetam to elderly patients, especially when prescribing to those with a history of renal impairment.
Abstract: Background : Compared with traditional antiepileptic drugs, levetiracetam has a unique mechanism of action and unique properties, including predominant renal excretion and lack of drug-drug interactions. In the elderly, depression associated with levetiracetam has not been reported. Case summaries : A 73-year-old black man (height, 172.7 cm; weight, 92.7 kg; body mass index [BMI], 31 kg/m 2 ) with stage 4 kidney disease was taking levetiracetam 500 mg BID for partial complex seizures. After 5 months of taking medication, new-onset depression, evidenced by depressed mood, weight loss, fatigue, and appearing withdrawn, was noted in this patient. Levetiracetam was discontinued by order of the patient's primary care physician. At a follow-up appointment 4 weeks later, the depressive symptoms had nearly resolved. The patient's Naranjo Adverse Drug Reaction Probability Scale score was 6, indicating levetiracetam to be a probable cause of depression in this patient. In a second case, a 92-year-old white woman (height, 154.9 cm; weight, 54.5 kg; BMI, 22.7 kg/m 2 ) with existing chronic kidney disease and new-onset partial seizure, likely due to a meningioma, was initiated on levetiracetam 500 mg once daily. Depressive symptoms (eg, anhedonia, hypersomnolence, decreased appetite) were noted within 5 weeks. Cessation led to improvement in mood and cognition within 8 days. Based on this patient's Naranjo Adverse Drug Reaction Probability Scale score of 6, levetiracetam was a probable cause of depression in this patient. Conclusions : Levetiracetam was a probable cause of depression in these 2 elderly patients. Cautious use and additional monitoring may be necessary when prescribing levetiracetam to elderly patients, especially when prescribing to those with a history of renal impairment.

Journal ArticleDOI
TL;DR: Viewing of live health insurance presentations and adequate health literacy were associated with greater awareness of important pharmaceutical cost-assistance programs in this study in low-income, elderly individuals, and the findings suggest that use of live presentations, in addition to health literacy materials and messages, may be important strategies in promoting knowledge of and enrollment in state and federal pharmaceutical cost
Abstract: Background: Lack of awareness may be a significant barrier to participation by low- and middle-income seniors in pharmaceutical cost-assistance programs. Objective: The goal of this study was to determine whether older adults’ awareness of 2 major state and federal pharmaceutical cost-assistance programs was associated with the seniors’ ability to access and process information about assistance programs. Methods: Data were gathered from a cross-sectional study of independently living, English- or Spanish-speaking adults aged ≥60 years. Participants were interviewed in 30 community-based settings (19 apartment complexes and 11 senior centers) in New York, New York. The analysis focused on adults aged ≥65 years who lacked Medicaid coverage. Multivariable logistic regression was used to model program awareness as a function of information access (family/social support, attendance at senior or community centers and places of worship, viewing of live health insurance presentations, instrumental activities of daily living, site of medical care, computer use, and having a proxy decision maker for health insurance matters) and information-processing ability (education level, English proficiency, health literacy, and cognitive function). The main outcome measure was awareness of New York's state pharmaceutical assistance program (Elderly Pharmaceutical Insurance Coverage [EPIC]]) and the federal Medicare Part D low-income subsidy program (Extra Help). Results: A total of 269 patients were enrolled (mean [SD] age, 76.9 [7.5] years; 32.0% male; 39.9% white). Awareness of the programs differed widely: 77.3%) knew of EPIC! and 22.3% knew of Extra Help. In multivariable analysis, study participants were more likely to have heard of the EPIC program if they had attended a live presentation about health insurance issues (adjusted odds ratio [AOR], 3.40; 95% CI, 1.20–9.61) and less likely if they received care in a clinic (AOR, 0.45; 95% CI, 0.23–0.92). Awareness of Extra Help in the multivariable models was more likely among study participants who had viewed a live health insurance presentation (AOR, 3.35; 95% CI, 1.55–7.24) and less likely for those with inadequate health literacy (AOR, 0.15; 95% CI, 0.03–0.74). Conclusions: Viewing of live health insurance presentations and adequate health literacy were associated with greater awareness of important pharmaceutical cost-assistance programs in this study in low-income, elderly individuals. The findings suggest that use of live presentations, in addition to health literacy materials and messages, may be important strategies in promoting knowledge of and enrollment in state and federal pharmaceutical cost-assistance programs for low-income seniors.